Pregnant Drug Users Look to Get in, Not Out of Jail : Health: With a shortage of public obstetric care, some women see jail as their best access to medical treatment.

SANTA ANA —  Mary Lievanos, 31, is eight months pregnant, but for her, Orange County’s sophisticated network of health care is in another world.

Most obstetricians see the heroin tracks on women like Mary and turn them away. Drug-addicted mothers can deliver drug-addicted babies, many with birth defects that lawyers might blame on physicians five, 10 or 15 years later.

Hospitals see the MediCal papers in their hands, envision a tangle of red tape and slow payments and tend to refuse to admit them for delivery. Even though the law says emergency rooms must accept women in labor, some women tell of being sent away with cab fare and directions to the hospital down the road.

But Lievanos knows that in spite of all that, she can have her baby delivered by a doctor in a hospital by using the paper she’s been saving in her purse.

It’s a misdemeanor warrant for her arrest, a get-into-jail-free card.

Used at the right moment, it could put her in the Orange County Jail women’s medical ward, which has already supplied much of her prenatal care during previous stays. Returning to jail, Mary would have a court-confirmed, constitutional right to free treatment. The medical attention denied her on the outside would be provided at county expense.

At any one time there are 30 to 40 pregnant women in the jail, and they deliver an average of three babies each month. Jail personnel are convinced that some arrange their own incarceration for that purpose.

“They get out soon after the delivery,” said Dr. Ernest R. Williams, medical director for the county’s jails. “They usually stay until they deliver, though. It’s amazing. I don’t know how they do it.”

The phenomenon is not limited to Orange County, Williams said. “I think if you go to any large jail in any fairly urban community, you’re going to find a segment of that population who’s there for that health care.”

In Los Angeles, “we’re getting some very clear-cut situations where people with AIDS have discovered, unfortunately, that they have better access to care in this environment, especially to some of the medications,” said Dr. John H. Clark, chief medical officer in the Los Angeles County Jail.

In Manhattan, street people flood the detention center’s clinic, where “they’re basically receiving the only care they’ll ever get,” said Dr. Budd Heyman, chief of the medical staff. “We in the prison are basically a community health clinic.”

In suburban McHenry County 55 miles northwest of Chicago, Sheriff George Hendle tries to avoid prisoners who are going to require expensive medical care. “If a woman comes in who’s pregnant, I usually try to work something out, get the bond lowered, recog them out (release them without bail). Because once we treat her, she’s ours; we have to follow up all the way. That’s state law.” Even in rural North Carolina, Scott Chavez of the National Commission on Correctional Health Care encountered a man who had committed a minor crime to be jailed and obtain insulin.

“I can’t give you numbers, but I can tell you that it’s being reported to us that it’s happening,” Chavez said. “It’s a terrible indictment of the nation’s health care system.”

In Orange County, Williams believes that pregnant women are the major exploiters of the jail health care system, due to the shortage of public obstetric care, especially for drug-using women.

A county task force has been studying the state of local obstetric care since 1989 and will turn its attention this year to the plight of drug-using mothers, a spokeswoman said. “That is this year’s major topic that we’re going to address,” she said.

“When I first came here (in 1989), people weren’t clamoring to get in for OB services,” Williams said. “But with the downturn in the economy and a reduction of those services in the community, people started to get incarcerated to take care of those problems.”

There hasn’t been a county hospital since 1976, when the Orange County Board of Supervisors sold theirs to UC Irvine. The renamed UCI Medical Center now has a clinic for high-risk pregnancies, “but traditionally they treat women with diabetes and other, more conventional problems,” said Mary Harris, director of ADVANCE, a group that tries to arrange medical care for pregnant drug users.

The clinic recently agreed to accept some substance abusers, Harris said, “but if I had to tell someone right now where they could get care, I wouldn’t have any direction to point them in.”

Carole Hatch is the jail’s obstetrics nurse practitioner, one of about 170 jail health workers.

“I have five or six inmates here right now for their third pregnancies with me,” Hatch said. “I get two or three new pregnant people every day that I see. I have got inmates who say, ‘Oh, yeah, I heard about you on the outside.’

“I hate to say it, but I think jail is their only alternative.”

Women who are obviously pregnant or test positive go to the jail clinic, where they receive extra blankets, extra milk at meals, prenatal vitamins and iron supplements, Hatch said. Prostitutes get antibiotics.

A nurse is on duty 24 hours a day. Doctors under contract to the jail examine the women regularly, administering ultrasound and blood tests. If the woman is older than 35, her amniotic fluid is tested. Delivery is at a hospital under contract with the county Health Care Agency.

And if she wants an abortion and will not be released in time to get one of her own, she’s given an abortion at a clinic in Los Angeles. “We have to provide what’s available on the outside,” Hatch said. “We were going to a clinic here, but our people were getting picketed (by anti-abortion protesters).”

The cost of caring for such cases is unknown. The county has budgeted $14.7 million for health care in its jails this year, and while 84,000 prisoners will receive medical attention from an interview to major surgery, no one knows how many are in jail solely for that purpose.

Hatch guessed that 5% of her pregnant prisoners are in that category. Williams is unwilling to guess.

“Significant would be what, 2%, 5%?” Williams said. “I just think that to go to jail to find health care is not a reason to go to jail.

“I think it’s a comment on what’s happening in the country today with regard to health care. You got big chunks of folks, millions of people, who are working and can’t afford health care. I mean, the discussion on the front burner today is what are we going to do about those people who cannot afford to get health care. National health care, some kind of program, is certainly on the horizon.”

Lievanos, never married, living “here and there,” taking methadone to avoid heroin, says she has already delivered three children who have been taken by authorities and adopted. This time, “I’d rather be in jail than to be out here. Because I do want to stay with this baby.

“I figure the only way you can stay clean is in jail,” Lievanos said. “I remember when I wasn’t pregnant, when I was getting tired of hustling just to make that money, I would go in there purposely just to get cleaned up and come out doing the same thing.”

Once she checked out of a hospital and left her baby behind because she was “too into drugs.” Once she delivered a child in a motel where she had gone to buy drugs. When you’re using heavily, she explained, “you don’t even know your contractions. I was having my contractions, and I thought I was sick.”

She has snapshots of her children, now 5, 6 and 7, whom she sees now and then. But “they don’t know me as their mom. You know, it hurts when I do see them. All I did was have the baby, but I never had a chance to be a real mother to them.

“But I got over that. That’s why I want to keep hold of this one.”

On the outside, women like Lievanos have two strikes against them when they try to find an obstetrician among the 150 or so listed by the local medical association.

Virtually all such women depend on Medi-Cal to pay their doctor bills, and that alone makes it difficult to find a doctor. Bothersome paperwork and slow payment have alienated physicians, said Dr. E. Michael Linzey, vice president of the Orange County Obstetrical and Gynecological Society. “We did a survey, and the majority of our doctors are not in favor of taking Medi-Cal patients.”

But worse, “with drug users, anything can go wrong with their babies,” Linzey said. “And there seems to be the belief, whether it’s true or not, that these people are more likely to sue because there’s not the attachment to the physician, the good doctor-patient relationship.”

Even avoiding high-risk cases, obstetricians find their malpractice insurance premiums to be among the highest in medicine--$45,000 to $55,000 a year, according to Linzey. “If somehow we could overcome the liability issue, I’m sure a lot of doctors would be willing to take care of these patients.”

In the meantime, the county Health Care Agency’s continuous search seldom yields more than 10 obstetricians willing to take such cases. “And they’ll take maybe two or three of our clients before they burn out and we go looking for another,” a social worker said.

The result is a classic Catch-22: Obstetricians don’t want to treat the pregnant heroin user, but to enter the methadone program and kick the habit, the addict needs proof that she’s under an obstetrician’s care. It’s a state regulation based on research showing that methadone mothers who get good prenatal care are more likely to have healthy, full-term babies.

The alternative has been jail. “If you’re a user or an alcoholic, you got no choice but to kick in there,” Lievanos said. “And for a lot of people, they can’t handle it. It’s not like doing it out here.”

The ADVANCE program is trying to help out by taking charge of women like Lievanos and shepherding them through the system, into methadone programs and away from jail. Women hear of the program through word of mouth or referral from jail health workers.

“A girlfriend of mine, she told me about this social worker that would help me,” Lievanos said. “When she said social worker, I got kind of, well, I had all my three children taken away because of my being dirty.”

But these social workers broke the “you make ‘em, we take’ em” image social workers have among drug mothers, Lievanos said.

Raquel Amezqua, one of only two “case managers” for ADVANCE, badgered a doctor into accepting Lievanos by promising to make sure she stayed off heroin and kept her appointments. She got Lievanos into the methadone program and birthing classes. She drives Lievanos here and there and checks on her regularly.

The program has had about 90 drug users or AIDS victims since the program started last July. About 75% are Latino and about 90% are heroin users.

“Out of 80 or 90, not more than 10 have wanted to go through adoptions,” Amezqua said. “The baby fills a void. We see a lot of repeats. It’s not like they planned them, but once they’re pregnant,” they want to keep them.

“Maybe mom gets the child back, maybe she doesn’t,” Amezqua said.

These women need help because “they’re so easily intimidated. We explain. We hold their hands. It’s very important. Our women know how to work the streets, but they haven’t a clue how to work the system.”

The exception: Those who have been in jail know that system well.

“The jail population is hard to work with,” Amezqua said. “The minute they’re out, they don’t know the resources available. They wind up wanting back in jail where everything is provided. They’re like children; that’s why they do so well in prison. Someone tells them when to get up, when to eat, what to do--everything.”

Getting into jail isn’t automatic. Lievanos’ friend Ruth Salinas said that when seven months pregnant, she went to a variety store, made sure she was watched, then stole some mascara. But police only gave her a ticket.

“It’s like out here, there’s not enough clinics,” she said. “I don’t know what they’re doing. They ought to have enough funds to help addicts who want to get cleaned up.”

She finally had her baby on the outside with the help of ADVANCE.

But others know the ropes better, including judges, some of whom have reputations for sentencing pregnant defendants to jail if it’s their only way to medical help.

“In some counties in California, there’s a situation evolving where courts are directing people to jail when the issues involve pregnancy and prenatal care and substance abuse,” said Clark, a director of the American Correctional Health Services Assn.

“The quality of prenatal care in the jail environment is pretty good, and patients don’t miss appointments. A captive audience, so to speak. And they get their three square meals and vitamin supplements and not ready access to drugs.

“Judges are sensitive to this--without a doubt in smaller counties. I won’t name any names. And it’s not only in California but across the country.”

Some inmates complain that jail health care is slow and substandard. Says Salinas: “In jail, just to get two aspirins (inmates) have to put in 10 snivel sheets (written requests for treatment).”

But jail health officials, bolstered by a recent, complimentary grand jury report, say their medical services are equivalent to what’s available on the outside.

For pregnant women who return time and again, “it’s much more the feeling of coming home,” said Corinne Callahan, the jail nursing supervisor. “You know: ‘Hi, Mom, I’m pregnant, I’m on drugs, take care of me.’ ”

But there is the down side, too, said Lievanos. “Jail is the answer to a lot of problems, but after you get out, after you get out, that’s what you have to think about.”